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A Difficult Diagnosis

What is causing this patient's extreme exhaustion and headache?

Feldhausen, Daniela BSC, EMPA-C

Author Information
Journal of the American Academy of Physician Assistants: March 2020 - Volume 33 - Issue 3 - p 54-56
doi: 10.1097/01.JAA.0000654212.41559.3e
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CASE

Figure
Figure

A previously healthy 19-year-old female Army medic trainee presented to the ED with fever, chills, shaking, and a complaint of not feeling well.

History

The patient described a sudden onset of extreme exhaustion 3 days ago without inciting factors. In addition to severe fatigue, she reported a throbbing headache on day 2 of symptoms, for which she took acetaminophen. She stated that over the past 24 hours, her headache had become intractable with the onset of body aches, neck stiffness, and a subjective fever. These symptoms did not improve with the 500 mg acetaminophen taken earlier in the day.

The patient also described several episodes of rigors, noting uncontrollable shaking and hot flashes before her arrival in the ED, and moderate to severe pain in her hands and feet with slight touch. She reported a history of headaches, but nothing this severe or with altered sensation to touch in her extremities, and complained that any movement made her headache and neck pain unbearable. She denied cough, shortness of breath, chest pain, rash or lesions, nausea, vomiting, diarrhea, urinary symptoms, or vaginal discharge.

The patient stated she took oral contraception but was not sexually active. She had no known drug allergies and denied any significant past medical history or past surgeries. Her immunizations were up to date. She stated she did not use tobacco or vape, and did not use alcohol or illicit drugs. She lived in military training barracks and did not have any sick contacts or animal exposure. She had not traveled out of the country recently.

Physical examination

The patient was ill-appearing with an ashen color. Her vital signs were oral temperature, 103° F (39.4° C); BP, 123/74 mm Hg; heart rate, 101; respirations, 20; and SpO2, 100% on room air. She appeared to be in no acute distress when lying on her side, but had evident discomfort when she sat up for the examination.

On examination, there were no abnormal conjunctival findings, and her pupils were 3 mm, equal, round, and reactive to light with significant photosensitivity elicited. Ears, nose, and pharynx demonstrated mild edema, tonsils were 2+ and without exudates. Neck was supple without gross lymphadenopathy. Chest was nontender and clear to auscultation. She had a frequent dry cough, as noted by the clinician, but no adventitious breath sounds and her breathing was not labored; no cardiac murmurs were appreciated and the rhythm was regular. Abdomen was soft and nontender with normal bowel sounds. She had no tenderness to spine or back muscles and no costovertebral angle tenderness. The patient was warm to touch; her skin was dry with normal turgor. She had no lesions of the hands, feet, mucosa, or other areas of the body.

During the examination, the patient retracted her legs to pull her feet away when palpated, reporting intense burning pain. She additionally complained of pain with head and neck movements; however, true nuchal rigidity was not appreciated as she was able to fully nod yes without hesitation when asked. She had no motor deficit and exhibited normal range of motion of all extremities with 5/5 muscle strength. The patient was otherwise pleasant, oriented, and spoke in full sentences without difficulty.

Diagnostic testing

The patient's complete blood cell count was unremarkable, with a white count of 7,500 cells/mm3. Venous blood gas results were pH, 7.45; temperature-corrected carbon dioxide pressure, 32 mm Hg; bicarbonate, 22 mmol/L; base excess, -2 mmol/L; and lactate, 0.47 mmol/L. Complete metabolic panel and thyroid tests were unremarkable. Tests for pregnancy, rapid Streptococcus group A, influenza types A and B, and a urinalysis were all negative. The patient's head CT was normal.

Cerebrospinal fluid (CSF) studies revealed elevated mononuclear cells but otherwise normal glucose, protein, and cell count, with negative viral and meningitis/encephalitis panels. Cultures of blood, urine, and CSF were pending. A portable chest radiograph (Figure 1) showed a focal consolidation or mass measuring up to 5 cm in the right upper lobe without evidence of pleural effusion or pneumothorax.

FIGURE 1
FIGURE 1:
Radiograph showing a 5-cm mass in the upper right lobe

DIFFERENTIAL DIAGNOSIS

  • Hodgkin lymphoma
  • tuberculosis
  • aspergillosis
  • round pneumonia

OUTCOME

In adults, a lung mass is highly suspicious for malignancy. Hodgkin lymphoma is common in early adulthood (ages 15 to 40 years, usually people in their 20s); however, this diagnosis was unlikely given the patient's normal blood cell count and normal liver and kidney function tests. Tuberculosis, although more common in the military setting, was ruled out because the patient had a negative skin tuberculin test documented on military entry and no known exposure or other risk factors.

Aspergillosis is known to cause pneumonia and spread through the bloodstream to the brain and could explain the lung mass as well as the meningeal complaints of severe headache with photophobia, high fever, and neck stiffness. However, this is uncommon in patients who are not immunocompromised and the patient did not have CSF characteristics of fungal meningitis (low lymphocytes, reduced glucose, and elevated protein level). Pneumonia was high on the differential given the patient's complaints of extreme exhaustion and rigors in combination with fever and the cough noted by the clinician during the evaluation. This was further supported by radiology's preliminary chest radiograph report, which favored the mass as round pneumonia in the acute setting.

The patient was diagnosed with round pneumonia despite no complaint of cough, evidence of shortness of breath, normal lung sounds, and normal oxygenation on pulse oximetry as well as normal venous blood gas results. An additional diagnosis of aseptic meningitis was given because the patient's headache severity worsened with movement and her CSF findings showed elevated mononuclear cells with normal protein and glucose.

The patient fell in the low-risk group according to the pneumonia severity index (PSI), and her calculated CURB-65 reported a 30-day mortality risk of less than 0.6%.1 From these site-of-care decisions, she was considered appropriate for outpatient treatment. However, because she was in military training and lived in the barracks, internal medicine was consulted for admission to provide further treatment and monitoring as well as further evaluation of the 5-cm round upper right lung mass.

Given the patient's fever, 1 g of IV acetaminophen was immediately administered for fever and pain control; she also received a 1,000 mL bolus of 0.9% sodium chloride solution. Empiric IV antibiotics (vancomycin 1.5 g, ceftriaxone 2 g, and ampicillin 2 g) and an antiviral (acyclovir 600 mg) were started in addition to 8 mg of dexamethasone at time of lumbar puncture to cover for meningitis. Because the CSF viral and meningitis panels returned negative, no further treatment with antivirals was indicated once the patient was admitted. The fever, severe headache, body aches, and general malaise continued to be treated with acetaminophen. To cover for pneumonia, antibiotics were changed to azithromycin (first dose of 500 mg given IV, followed by 250 mg orally for 4 days) and IV ceftriaxone 1 g timed off the ED dose once, then changed to oral cefpodoxime 200 mg every 12 hours for 10 days.

While the patient was admitted, a CT chest was obtained for further evaluation of the lung infiltrate. It confirmed the upper lobe mass to be consistent with pneumonia; a follow-up chest radiograph in 6 to 8 weeks was recommended to assess for resolution. Endemic mycoses for lung mass and meningitis were considered further but with the patient's rapid response to antibiotics and supportive treatment as well as the length of time for endemic laboratory results to return, these were deferred to outpatient follow-up. The patient was hospitalized for 2 days and was discharged back to her unit in stable condition to complete the oral antibiotic therapy. Before discharge, she was scheduled with a 48-hour outpatient follow-up. During her follow-up, the blood and CSF cultures were confirmed negative and the patient was noted to be in improved condition. She was directed to return in 6 to 8 weeks for a repeat radiograph to ensure resolution of the mass. The patient relocated without completing the imaging but was contacted by phone and confirmed resolution of lung mass.

DISCUSSION

Pneumonia is clinically defined by the presence of lower respiratory tract dysfunction (dyspnea, cough, fever, and acute chest pain) with an associated radiographic opacity.2 Radiology literature first reported round pneumonia in 1954.3 The mass appearance is believed to be caused by underdeveloped pores of Kohn, with the absence of canals of Lambert limiting the spread of infection. These discrete holes and accessory connections in the walls of adjacent alveoli are absent in human newborns and develop at age 3 to 4 years. Because of this, round pneumonia is more common and well known in children and less frequently identified in adults.3,4

Diagnosis of round pneumonia, like other pneumonias, is based on clinical and radiological findings. Round pneumonia can appear as single or multiple nodular densities and favors the lower lobes. However, as demonstrated in this case study, it also has been reported in the upper lobes. Chest radiograph is the gold standard to diagnose pneumonia but cannot accurately distinguish viral from bacterial or give the bacterial cause, and imaging alone, especially in round pneumonia, cannot rule out other causes for the radiographic opacity.1 Additional imaging with plain radiographs or CT may be needed to evaluate patient response to treatment or if other causes are suspected.1,2

Given the nodular appearance, round pneumonia can be mistaken for pulmonary infarction or malignancy in adults. This creates not only a diagnostic challenge but possibly a delay in antibiotic treatment and exposure to unnecessary diagnostic testing and procedures such as bronchoscopy and lung biopsies.5 Conversely, in children with radiographic and clinical symptoms suggestive of pneumonia, the clinician must consider a primary lung neoplasm, as delayed diagnosis of inflammatory myofibroblastic tumor, metastatic Wilms tumor, and congenital bronchogenic consolidation have been reported.4,6 Obtaining a good history of present illness, review of systems and clinical examination with laboratory studies can help to properly diagnose adults and prevent a delay of their care, and avoid a potentially life-threatening condition in children.

Like other community-acquired pneumonias, round pneumonia typically is caused by Streptococcus pneumoniae. Similarly, it is treated in the outpatient setting with oral azithromycin or doxycycline with cephalosporin added if hospitalized unless the patient has significant comorbidities, Pseudomonas infection, or other suspected or known causative agent. Significant comorbidities include chronic heart, lung, liver, or renal disease; diabetes; active cancer; and immunosuppression or use of antimicrobials within the previous 3 months.

In this case, the patient's chest radiograph and clinical presentation suggested an acute infectious process such as round pneumonia, and the laboratory results along with her response to treatment were reassuring. The PSI prognostic score and the severity of illness score calculated by the CURB-65 suggested that the patient was a good candidate for outpatient treatment.1 However, when the patient's living situation, initial presentation, and symptoms during the ED course were considered, she was deemed appropriate for admission. This exemplifies the importance of clinician determination of subjective factors to supplement the objective criteria and use shared decision-making with patients and family members.

CONCLUSION

Round pneumonia is a form of pneumonia commonly seen in children due to the lung's developmental stage, but it also can occur in adults. Clinicians in primary and acute care should consider round pneumonia in adults with a history and clinical findings consistent with pneumonia. Consider primary lung neoplasms in children diagnosed with round pneumonia who do not readily respond to antibiotic treatment.

REFERENCES

1. Nassisi D, Oishi ML. Evidence-based guidelines for evaluation and antimicrobial therapy for common emergency department infections. Emerg Med Pract. 2012;14(1):1–28.
2. Jadavji T. An evidence-based review of pediatric pneumonia in the ED. Emerg Med Pract. 2011;8(2):1–12.
3. Zhang Y, Yu YS, Tang ZH, et al Round pneumonia in an adult. Southeast Asian J Trop Med Public Health. 2014;45(1):207–213.
4. Silver M, Kohler S. Evolution of a round pneumonia. West J Emerg Med. 2013;14(6):643–644.
5. Çimen D, Bulcun E, Ekici A, et al Case of round pneumonia: pulmonary infarct and a rare situation that is similar with the lung cancer. Clin Respir J. 2015;9(4):512–515.
6. Naime S, Bandarkar A, Nino G, Perez G. Pulmonary inflammatory myofibroblastic tumour misdiagnosed as a round pneumonia. BMJ Case Rep. 2018;2018. pii:bcr-2017-224091.
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